Key governance areas for compliance in monitoring visits for providers

As we approach the 1st of December, here at Critical Success Solutions (CSS) we want to highlight key governance areas for aged care providers to be prepared for the monitoring visits that will commence post December 1st deadline. It is crucial to ensure compliance with the new strengthening governance requirements. This is an area we have been actively assisting Home Care and Residential providers navigate in the past 12 months.

Feedback from Audits and Reviews

During our reviews, as well as from our network that informs us of the Aged Care Quality and Safety Commission reviews and questioning , we are finding that there is particular scrutiny on Governing Bodies, as well as whether the organisation has a Quality Care Advisory Body (QCAB) and Consumer Advisory Body (CAB). Our auditors as well as Commission assessors raise concerns and questions in various areas over the past 12 months:
  • Suitability of Board and body membership, emphasising skills, qualifications, and Independence.
  • Lack of diversity in membership of the various bodies.
  • Absence of suitably qualified clinical members in the Governing Body – Clinical independent members not having relevant or up to date clinical skills.
  • Lack of documentation regarding governing body member recruitment. No interview, reference checks, letter of appointments, position description documentation.
  • Inadequate induction for governing body, QCAB and CAB members, especially in the roles and responsibilities of key personnel.
  • Insufficient education for Governing Body on approved provider responsibilities, reform updates and clinical governance.
  • Inadequate documentation for follow-up and investigation by the Governing Body and QCAB in response to key risk areas.
  • Misalignment of current Governing Body Key Personnel with Commission information.
  • Ineffective reporting to QCAB and CAB, with poor data management.
  • Lack of documentation for key personnel suitability and failure to meet material notification requirements.
  • Poor documentation and acknowledgment by the Governing Board regarding identified areas of risk.
  • Inadequate minute-taking that does not reflect meeting agendas accurately.
  • Non-compliance with QCAB and CAB requirements. 100% of consumers/ representatives population have not received an offer to join the CAB?
  • Insufficient information on change management processes and other governance structures.
  • Poor risk management approaches by governing body – no risk appetite or tolerance noted.  
  • Governing Board Systems and Processes
    • Lack of best practice corporate governance processes.
    • Not conducting Key Personnel suitability assessment – remember that all providers now should have this completed as it started in from Dec 2022.
    • Inadequate systems for building capability and skills in Leadership Teams.
    • Outdated policies and procedures not reflecting legislative changes.

Steps to Strengthen Governance

  1. Ensure all relevant documentation regarding the appointments of members has been completed.  
  2. Review Strengthening Provider Governance documentation on the Commission website.
  3. Implement the red flag approach for critical decision making.
  4. Document all interactions between Governing board, QCAB and CAB.
  5. Review and ensure compliance with the requirements of your Board, QCAB and CAB members.
  6. Identify and document Key Personnel and commence suitability assessments.
  7. Regularly update Continuous Improvement Plan to capture Strengthening Provider Governance changes.
  8. Develop capability and skills through individualised plans for all members
  1. Ensure all members have comprehensive induction.
  2. Develop comprehensive education program for members
  1. Ensure Governing Body systems reflect best practice.
  2. Allocate appropriate resources to QCAB and CAB such as administrative support and induction.

At CSS, we understand the evolving landscape of aged care governance and the challenges providers face in meeting the new requirements. Our team is dedicated to supporting organisations in achieving excellence in governance. We can assist you through providing:

  • Position Descriptions: We can provide tailored position descriptions for key roles within your organisation (including PD for Independent Non-executive Board Director and Clinical Director), ensuring clarity in responsibilities and expectations.
  • Key Personnel Suitability Matters Checklist: Our expertise includes developing and maintaining a comprehensive checklist for the annual review of KP Suitability Matters, aligning with regulatory requirements.
  • Independent Members Support: Recognising the significance of Independent members as key personnel, we can guide you in identifying, recruiting, and maintaining a diverse and qualified board.
  • Governance Documentation: Leverage our Board Governance Manual, a robust resource designed to streamline governance processes, forms and templates to provide a comprehensive reference for Board members and Leadership Teams.
  • Induction Support: Our Induction Program for new members facilitates the induction of Governing Board, QCAB, and CAB members, ensuring a smooth onboarding process. Our Board Governance Manual includes specific references and tools for Governing Body members.
  • Governance Education Program: Crafted for both Board and Leadership Team members of residential and home care organisations. Stay informed on Approved Provider responsibilities, reforms and clinical governance.

Important Reminder: As you prepare for the approaching changes and seek to enhance your governance structures, CSS is here to collaborate with you.

Contact: Fleur Hannen,
Email: or
Mobile: 0414588795 or Office: 02 90520292

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